Healthcare Provider Details

I. General information

NPI: 1124806682
Provider Name (Legal Business Name): MARIAH WALLACE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 S CHURCH ST
MT PLEASANT PA
15666-1702
US

IV. Provider business mailing address

508 S CHURCH ST
MT PLEASANT PA
15666-1702
US

V. Phone/Fax

Practice location:
  • Phone: 724-547-7092
  • Fax: 724-547-7096
Mailing address:
  • Phone: 724-547-7092
  • Fax: 724-547-7096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067651
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: